Awareness and knowledge of periodontal disease among Saudi primary school teachers in Aseer region.

BACKGROUND: The consequences of periodontal disease are not limited to the oral cavity. As schools are considered to be one of the principal systems in preventive oral health, teachers' knowledge pertaining to the periodontal disease, their awareness with regard to its implications and their role in increasing the awareness of the students regarding this disease comprises only one aspect with respect to the prevention of the periodontal disease. Therefore, the aim of this study is to investigate the baseline awareness and knowledge of Saudi primary school teachers regarding the periodontal disease.
MATERIALS AND METHODS: For this purpose, a questionnaire was distributed among the participants of the study.
RESULTS: It was observed that 91.4% of the participants reported that the periodontal disease does not need any treatment although 70% of the participants believed that it could result in tooth loss, and 95% considered the periodontal disease to be a preventable disease. Moreover, social media (44%) and television advertisements (39%) were the main sources from where they acquired information about the periodontal disease.
CONCLUSIONS: Most participants have heard about the importance of periodontal health but are not sufficiently aware of its consequences and negative effects on their body. They are used to receiving information about periodontal diseases from nondental clinics and unreliable sources. This creates misconceptions. Although the participants were keen to attend educational events on periodontal health, the lack of medical communication between the health practitioners and the general public is evident. Mostly, investigated areas and individuals do not have any educational means to be aware of periodontal health.

INTRODUCTION

Periodontal health is the absence of signs and symptoms of gingival and destructive periodontal diseases or any tissue status outside of the normal range. On the other hand, periodontal disease is a multifactorial disease that impacts the various components of the periodontium or only one of them. It is a multifactorial disease, whose consequences are not limited to the oral cavity. On the contrary, they could affect different remote organ systems and cause unwanted events for medically compromised people.[1] The periodontal disease is not a local disease, but it is one of the major oral health issues worldwide. It may lead to many health consequences. The National Health and Nutrition Examination Survey confirms a high prevalence of periodontitis with almost 50% of it being influenced. This report was conducted was for the period between 2009 and 2012, for the adults in the United States of America (USA).[2] In India, Kumar et al. assessed the prevalence and severity of periodontal diseases in type 2 diabetes mellitus (DM). Among 1000 participants examined, the prevalence of periodontitis was found among 91.7% of them.[3] On the same regard, there is a study published by Al Qahtani et al.[4] that assessed the prevalence of periodontal diseases in Abha city, Saudi Arabia. They found that the prevalence of gingivitis was 48.8% and the prevalence of chronic periodontitis with different degrees of severity was 51.2%. Hence, in Saudi Arabia, the periodontal diseases are raising an issue that needs to be investigated further.

The untreated periodontal disease showed to be leading toward more complicated situations for oral cavity structures. Bone resorption, the mobility of teeth, and tooth loss are the most common consequences of untreated periodontal disease.[5] In addition, the consequences of periodontal diseases can even go beyond this. The relation between the periodontal diseases and systemic diseases has been discussed in many ways through the literature, and the presence of bidirectional ways between them has been hypothesized. Many systemic diseases were discussed through the literature. They include cardiovascular diseases (CVDs), DM, adverse pregnancy outcomes, and osteoporosis. Debatable results are present around most of the systemic conditions in their association with the periodontal diseases, but many association studies have reported supporting results, and there is evidence that this association has a biologically feasible basis.[6] For instance, Loos BG studied the systemic markers of inflammation in periodontitis. The author stated that it should be expected that locally produced proinflammatory immune mediators, such as interleukin-1 (IL)-1, IL-6, tumor necrosis factor alpha, and prostaglandin E are dumped into the systemic circulation and subsequently may exert effects on distant organ systems.[7] Moreover, Stanko and Izakovicova reported that DM increases the risk and severity of periodontitis. Periodontal diseases can aggravate insulin resistance and affect glycemic control. They also stated that periodontal treatment improves glycemic control in type 2 diabetics; control of periodontal infection is not only important for oral health, it may also improve overall health.[8] The data form the study of Esfahanian et al. indicate a greater tendency to lose alveolar bone in participants with osteoporosis. This indicates that osteoporosis should be considered a risk factor for periodontal disease progression.[9]

Through the literature, few studies investigated the awareness and knowledge of the primary school teachers regarding the periodontal disease while many studies investigated other aspects and attitudes of the teachers toward oral health in general.

A study was conducted in Kuwait by Hissah and Fatemah[10] that investigated the knowledge of the teachers and the students of preventive methods of periodontal diseases and dental caries. They found that a high percentage of teachers is not involved in educating their pupils and do not think that it is a part of their job to do so. Another study by Haleem et al.[11] concluded that dentist-led, teacher-led, and peer-led strategies of oral health education are equally effective in improving the oral health knowledge and oral hygiene status of adolescents. Moreover, Azodo and Umoh[12] investigated the awareness and knowledge of periodontal diseases among Nigerian primary school teachers. They concluded that the majority of the participants showed poor awareness of etiology, age and gender predispositions, manifestation, complications, and preventable nature of periodontal diseases. They also found that the vast majority of them were interested in learning about periodontal diseases. Another study was conducted in Brazil by Maranhão et al., which evaluated the levels of knowledge and attitudes toward the oral health of preschool teachers. They concluded that teachers showed poor knowledge of the etiology of periodontal diseases.[13] In Northern Israel, a study was conducted among Arab school teachers. The study revealed that the teachers had positive attitudes toward enlightening the parents about the importance of oral hygiene and tutoring the children about preventive dentistry while that they were less motivated about being involved in dental health school programs.[14] In Tanzania, in-service teachers and teacher trainees were regarded as moderately informed about oral health is some aspects and poorly informed in others, thus affecting their attitude, oral health status, and behaviors regrading oral health.[15]

The schools are places where students spend around 6 h of their day time. Therefore, schools are considered one of the principal systems in preventive oral health. Teachers' awareness of the importance and implications of the periodontal diseases and their role in increasing the awareness of the students regarding this disease is one aspect of the prevention of the periodontal disease. However, there is a lack in the literature of the studies that aimed at investigating the baseline knowledge and awareness of periodontal diseases among the primary school teachers.

Considering the lack of studies discussing this topic in Saudi Arabia and the importance of baseline information in developing preventive policies and strategies, thus, this study aims to investigate baseline awareness and knowledge of Saudi primary school teachers regarding the periodontal disease.

MATERIALS AND METHODS

Ethical approval

It was obtained from the Institutional Review Board (IRB) of King Fahad Medical City with log number: 17-145E, registration number with OHRP/NIH, USA: IRB 00010471 and registration number with KACST KSA: H-01-R-012.

Study population

A cross-sectional study was conducted among the government primary school teachers in Asser region, Saudi Arabia. In this study, we randomly selected the participants by stratified sample size method. Based on the geographical distribution and administrative division, data that were obtained from the website of the Emirate of Aseer region, we divided the region into five centers or strata. The five centers were as follows: Abha and its suburbs, Muhayil Aseer, Al Majardah, Al-Namas, and Al Darb. For each center, we randomly selected four primary schools. Of these schools, two were for females and two for males. For this, five Saudi dentists registered in the Saudi Commission for Health Specialties with valid registrations, who were recruited for the distribution and collection of the questionnaires. We interviewed the dentists before starting the study and discussed the study's objectives and aims.

Tool of the study

For data gathering and collection, we constructed a self-developed, self-administered, and validated questionnaire. The questionnaire was written in Arabic to ensure that the questionnaire was easy and understandable, it was pretested twice on 30 teachers who were not included in the study. The questionnaire comprised of 17 questions divided into three parts. The first part included basic questions related to the age, sex, educational level, and educational experience. The second part of the questionnaire included questions to investigate the baseline knowledge of the participants regarding periodontal disease while the third part was designed to assess the practice and awareness of the participants toward the preventable nature, the importance of students' awareness, and the influence of teeth brushing on periodontal health. The results were represented in numerical form, computed, and analyzed using Statistical Package for the Social Sciences (International Business Machines Cpro. (IBM), Statistical Package for the Social Sciences (SPSS), version 24) 24th edition.

Validity and reliability of the study tool

The questionnaire was developed by the first author by gathering the relevant questions from the literature and taking the questionnaire developed by Azodo and Umoh[12] as a guide. We validated the questionnaire by asking two periodontists to revise it and to propose their suggestions. Using average congruency percentage, the average of the scores reported by both periodontists was 100%. Meanwhile, on the 4-point Likert scale, they asked to review the relevance of each question by choosing one of the following numbers: 1-not relevant, 2-somewhat relevant, 3-relevant, and 4-very relevant. Then, the content validity index for individual items (I-CVI) was calculated, and it was I-CVI = 0.97.

The questionnaire was pretested on selected 30 teachers. And to investigate the stability of the questionnaire, we retested the same teachers 1 week after. Both the tests showed same results, that is, they choose same answers and agreed that it was easy and understandable. Moreover, the collectors, the selected dentists, showed 88% interrater reliability using tables of agreements.

Sample size calculation and statistical analysis

Using G power software to calculate the sample size at alpha error a = 0.05, effect size = 0.2, the level of significance was <0.05, and power at approximately 0.95, the minimum sample size was 262. For insuring that the responses are not lesser than the minimum sample size and for randomization purposes, we distributed the questionnaires to all the teachers in the selected schools. After we collected the data from the participants, we coded them to be eligible for statistical analysis by SPSS; then we entered them into the software. The data were presented in form of frequencies, percentages, and cross-tabulation.

The data in this study were subjected to descriptive statistics using Statistical Package of the Social Sciences version 24 (SPSS 24). Meanwhile, the periodontal awareness was considered as a dependent variable while demographic characteristics were considered as an independent variable. For this, Chi-square test was used to test the association and P = 0.05 for significance level.

RESULTS

We distributed the questionnaires for all the teachers in selected schools. The number of distributed questionnaires was 535. After the collection of the responses, we excluded all the incomplete responses. Finally, the complete collected responses were 419.

Table 1 shows the demographic characteristics of the participants. The mean age of the participants was 38.7 with 7.1 standard deviation. The age of the participants was somewhere between 22 years and 59 years. Participants ≥40 years were 45% of the final sample while the females were 61% of the final sample. Of the final sample, 272 participants (65%) were graduates and the majority of the participants, that is, 289 (69%) spent 10 years or less in the primary school teaching field [Table 1].

Table 1

Demographic characteristics of the participants

When we inquired the participants about the need for the treatment of periodontal disease, 383 (91.4%) of them reported that the periodontal disease does not need any treatment [Table 2]. Regarding the sources of information of periodontal disease, the vast majority of the participants reported that the social media and television advertisements (TV ads) were the main sources for getting their information. The participants that reported who usually got their information about the periodontal health from social media were 44%, and that from TV ads were 39%. The age showed a significant relation with P = 0.003 [Table 2].

Table 2

The need for the treatment of periodontal disease

Of our sample, 141 participants (34%) reported that smoking is the main cause for periodontal disease. Calcium deficiency and Vitamin D deficiency followed with 22% and 17%, respectively [Table 3]. In this study, 192 (46%) of the participants reported that gingival bleeding is the only sign of periodontal disease [Table 4]. These results showed the statistical significance when related to the demographic characteristics of the participants.

Table 3

Participants’ awareness of the common causes of periodontal disease

Table 4

Participants’ awareness of periodontal disease signs

Table 5 shows that the majority of the participants in this study (70%) were aware that the periodontal disease could lead to tooth loss with 2:1 female to male ratio, where 59% of them had 10 years or less of experience in the field (P = 0000) [Table 5].

Table 5

Participants’ awareness of periodontal disease consequences

As shown in Table 6a, the majority of the participants (81%) were aware that wrong brushing techniques could affect periodontal health, of which females comprised of 65% of them [Table 6a]. Moreover, a total of 400 participants (95%) considered the periodontal disease as a preventable disease, where the females comprised of 59% of the total participants [Table 6b]. These findings showed a statistical significance when related to gender (P = 0.001).

Table 6

The participants’ awareness of preventable nature of periodontal disease and their experiences in periodontal health awareness education

The majority of the participants in this study (71%) reported that there were no educational materials included in the courses that were introduced by them while 29% of the participants reported the opposite. Of those who reported the opposite, the number of responses increased with a decrease in the years of experience (P = 0.000) [Table 6c]. In the same regard, 58% of the participants in this study had never attended any lecture on periodontal health. Of them, 65% were females, and 81% spent 10 years or less in this field. This finding showed a statistical significance when related to the years of experience (P = 0.001) [Table 6d]. Moreover, the vast majority of the participants (98%) were aware of the need for periodontal health and disease awareness, where the females comprised of 61% of the total participants (P = 0.008) [Table 6e].

DISCUSSION

Most of the individuals are unaware of the consequences of untreated periodontal diseases and the relationship between the periodontal diseases and the diseases that affect the other organs within our bodies, such as diabetic and CVDs. Meanwhile, there is a lack of knowledge among the general public regarding this relationship. An essential step to change the misconceptions or to create new concepts is to focus our efforts on the awareness and prevention side by side with the therapeutic one. Therefore, proper knowledge of prevention of periodontal diseases becomes one of the important ways for achieving good periodontal health and avoiding undesirable consequences.

Knowing that the vast majority of participants (91%) in this study do not believe that periodontal diseases need treatment, it is expected that the prevalence of periodontal diseases is high in the region, and this corresponds to what Al Qahtani et al.[4] reported in his study. Taking into account the technological revolution that Saudi Arabia has been experiencing lately, it is not surprising to know that social media and TV ads are the largest source of information for the general public. They constitute the majority of the population that is around 44% and 39% for social media and TV ads, respectively. These results are similar to the results of the study conducted in Nigeria among Nigerian primary school teachers. The authors reported that 33.9% of their participants used to take the information regarding the periodontal disease from TV ads.[12] On the other hand, these results make us reconsider the traditional education methods and give us an overview of the impact of social media channels in communicating, facilitating, and receiving information for the general public. Actually, studies on this subject in Saudi Arabia are almost nonexistent, making the comparison with studies from the same region and on the same subject impossible. In other countries, Savage[16] investigated the periodontal disease among the Nigerians. They encouraged the use of the electronic media to enhance the periodontal health awareness.

In this study, we evaluated the knowledge of the participants regarding the common causes of periodontal diseases. The participants who reported smoking to be the main cause for the periodontal disease were 34%, followed by calcium deficiency and Vitamin D deficiency by 22% and 17%, respectively. In Puducherry, Sekhar et al.[17] assessed the perception of school teachers toward oral health. They found 15% of the participants felt that avoiding smoking would also maintain gingival health. They also found around 59% felt that Vitamin C could reduce gum bleeding. Meanwhile, Asa'ad et al.[18] assessed the perception of pregnant women in Saudi Arabia toward the influence of periodontal disease on pregnancy. Taking into account, the difference in the study's population and aim, we compared our findings with this study. The participants in Asa'ad et al.[18] study's who believed that smoking has a negative effect on periodontal health were 96%. These findings were reported by both Sekhar et al.[17] and Asa'ad et al.[18] were similar to some extent to our findings, where 34% of our participants rated smoking as the main cause of periodontal disease. Recently, smoking has received a lot of attention in Saudi Arabia. The Saudi society has been exposed to many awareness campaigns about smoking and its effects in different ways. This provides a logical explanation for public awareness of the impact of smoking on health in general.

Many studies through the literature have discussed the causes of tooth loss. In general, tooth loss was ranked as the first or the second cause of tooth loss in adults.[1920] In general, the participants in this study showed high awareness when they were inquired about whether the periodontal disease could lead to tooth loss or not. In fact, females showed around double awareness when compared to males. As the results showed, awareness increased with age. These findings are consistent with the results of many other studies. Al Shammery and el Backly[21] studied permanent tooth loss among adults and children in Saudi Arabia. They concluded that tooth loss was directly associated with the increase in age and was influenced by age and socioeconomic status.[21]

When periodontal disease occurs, treatment is the correct way to eliminate the disease. The lack of treatment, eventually, is likely to lead to tooth loss. In our study, the main causes of tooth loss that we reported were dental caries and periodontal disease. They comprised 80% of the reported causes. Of these causes, 28% were for the periodontal disease. These findings came parallel to the ones found by van der Velden et al.[1920] Moreover, the majority of the participants in this study were aware that the wrong brushing technique could affect the periodontal health. In addition, 95% of the participants believed that the periodontal disease is a preventable disease, which sheds light on the weakness in the awareness activities regarding periodontal health.

Failure to adopt educational courses in oral hygiene in primary school curricula or at least to encourage their activation in extracurricular activities will be reflected directly on the student health culture, especially at this critical school stage. Where the educational activities are welcomed by almost all teachers, only 42% of them got the opportunity to attend activities related to periodontal health. These could reflect, to some extent, the need for new policies that can effectively increase the awareness of the public toward the periodontal health.

CONCLUSIONS

Most participants have heard about the importance of periodontal health but are not sufficiently aware of its consequences and negative effects on their body. They are used to receiving information about periodontal diseases from nondental clinics and unreliable sources. This creates misconceptions. Although the participants were keen to attend educational events on periodontal health, the lack of medical communication between the health practitioners and the general public is evident. Mostly, investigated areas and individuals do not have any educational means to be aware of periodontal health. Although the study achieved its aim, there were some limitations. The accessibility to female teachers was an issue due to local customs in the region that limit gender communication and the lack of female collector in the study team. Moreover, future studies should include a wider range of population to include participants from different cultures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.